According to hospitals and healthcare organizations, patients, staff, and other stakeholders should all be safe. The government, non-governmental organizations (NGOs), insurance companies, professional groups, and patients are concerned about the quality and security of healthcare services. The Quality Council of India (QCI) established NABH to provide accreditation services to healthcare enterprises. NABH’s official name in the medical industry is National Accreditation Board for Hospitals and Healthcare Services. Its primary purpose is to urge healthcare systems to improve and safeguard patients on an ongoing basis. Furthermore, NABH promotes medical tourism in the country and recognizes accredited institutions on a global basis. Here are a few of the challenges that organizations typically encounter while they are preparing for NABH accreditation.
- A limitation of Core Team members: The representatives of the nursing team, quality assurance, human resources, NABH awareness training, engineering, microbiologists, housekeeping, front office, food and beverage, MRD, and pharmacy must all be a part of the core team. The core team, along with functional leaders, must conduct a thorough gap analysis involving the objective elements of accrediting requirements across all divisions. To complete the responsibilities & meet the necessary standards for the firm, the core team will have the full backing of the upper management.
- Inconsistent procedures and procrastination: Most departments not have documented and implemented SOPs. Before embarking on the accreditation journey, the core accreditation team must face the major issue of breaking the inertia and ensuring that the SOPs are prepared on time by each department. The implementation of SOPs at the ground level is critical to the success of accreditation, which is accomplished through interdepartmental training. The audit observations, gap analysis, and gap correction are related to a department’s major result areas to ensure minimal non-compliance.
- Unsafe Environment: To guarantee a safe environment for patients and workers, the organization must try to enhance the hospital infrastructure.
- Adherence to national building codes on fire standards.
- Reworking the bilingual signs is necessary.
- HEPA filtering and OT direct excess should be managed; the air conditioning and laminar flow in OT must be improved.
- The objectives for patient safety should be met.
- All necessary committee meetings must be held properly by the organization, with thorough documentation.
- Improper Documentation: The errors in the NABH documents and records, such as unsigned treatment orders, incomplete discharge forms, and incomplete prescription orders, need to be addressed most. The highest levels of government must recognize how sensitive the subject is and take action. The resident medical officers are essential in minimizing these mistakes. A team of medical officers must oversee the activity at the ward and the medical records office while developing a checklist to verify patient files.
- Untrained Staff for Emergency Preparedness: The training department must determine the training requirements for the entire hospital as well as each department. It is necessary to identify and map the trainers for each activity in the training schedule. It is required to perform both laboratory and practical emergency training, and feedback from both must be critically assessed and presented to the core team.
- Lack of acceptance of the Data-Driven Approach: As committees record and analyse quality indicators/metrics like surgical site infection and patient satisfaction index, accreditation forces a healthcare company towards a data-driven strategy. So, the hospital can proceed towards the road of everlasting improvement with the support of the top management effort in quality improvement initiatives.
- Partial implementations of Laws and Regulations: Obtaining and maintaining permits for blood banks, pharmacies, and lifts are included in the list of regulatory requirements before accreditation. Additionally, the hospital needs to centralize tracking of all of these before applying for accreditation. Also, all department heads must begin prioritizing the sharing of all documents with management and the legal department.
- Inconsistent Work: The timetable is crucial for obtaining accreditation. After the accreditation body’s pre- and post-evaluation, there is a set amount of time for non-compliances to be corrected. All of the staff of the healthcare business must be eager and enthusiastic to complete the optimal quality work on time. The core group will continue to assist the staff in advancing this process.
- Having Misconceptions regarding Accreditation: All stakeholders must know that Accreditation benefits them all. Accreditation also demonstrates a commitment to quality care. Accreditation also provides access to reliable and certified information on facilities, infrastructure, and level of care.
- Inadequate Inventory Control Measures: Considering the large number of stores across the healthcare organizations, and drugs and consumables kept in each sub-store and patient area, it is a major challenge to identify expired and near-expiry drugs.
Also, the employees must understand and know what the accrediting body is looking for, how to read and interpret the accreditation requirements and know what are the benefits of getting accredited. This will help them to work towards it with better focus and enthusiasm. If you are well-prepared and have good project management, you should be able to avoid these difficulties and achieve your accreditation.
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